Again, there's going to be a fair amount of overlap. This is not a very evidence-based talk, and there's not a lot of great videos to show, but hopefully I can share some tips and tricks. So it's funny, but how do I know I was ready for complex ESD when naturally in my head were Norio's voice and Professor Yahagi's voice? So they have been entirely part of my entire ESD journey, and I can actually listen to the voice and say, Amrita. You'll learn in my story that Norio was my first mentor in ESD, and Professor Yahagi said this to me when I presented a video in the first ESD course that I was invited as faculty and asked, he said, are you crazy? Do I deal in ESD? I always go back to that and think, am I being a little bit crazy in these cases that I'm doing? So I consider that my grounding. But I'll hopefully just share how I've come to that point where these voices are very valuable in the way you think about what you should do and what you can do and what you maybe try to do that you didn't think you could do. So the first question is really, what counts as difficult ESD? All the videos that we've shown you probably would count as that. They're all complex. They all have complications. There are things that needed to be added. There really isn't a very set definition. This, I would say, is very dependent on the operator. What's difficult for Dr. Yahagi is Professor Yahagi is probably never, ever should be attempted by many of us. But really, these definitions depend, in the literature, on a dissection time, rate of complete resection, whether or not operators need to change, and then, of course, complications. So I mean, if we just look anatomically at some of the things that have come up as possible, indicators of difficult ESD, you can see for the stomach, it's considered to be lesions larger than two centimeters, locations in the upper third of the stomach, along the lesser curve in the fornix, ulcerated lesions around the posterior wall, those that have submucosal fibrosis or invasive, submucosal invasive cancer. And then in the esophagus, which is a more tubular structure, certainly the size and the degree of circumferential involvement. And in the colon, it really, there's a lot dependent on the classification system, such as the morphology, and we'll talk about this in a second. The location, whether there's fibrosis. If there's been a prior resection technique, and I find that in the United States here, this is mostly, most often the case, because you get referred lesions where somebody's attempted an EMR, or there's a recurrence, or they place a tattoo right under the lesion, which then turns a very easy resection into a very complex resection. Of course, colonic motility becomes a problem, as well as looping and ability to really get the endoscope in place. So there has actually been a little bit of work trying to classify what is considered a difficult lesion. This was a publication that actually looked at polyps overall, when you're looking at polypectomy, and based, kind of came up with a classification system based on size, morphology, site, and access. So size greater than 20, than 2 centimeters, location in the cecum, near the appendiceal orifice, ileocecal valve, or the anorectal junction, behind a fold, near flexure, or an angulated segment. And then morphology, and again, this was for polypectomies overall, but thick, stocked, pedunculated polyps, laterally spreading tumors, and submucosal fibrosis, or a non-lifting sign with injection. And then again, recurrent lesions, or cases where you have just a tremendous amount of strong colonic peristalsis. And each of these got a score, and they found that when you added these up, level 4 compared to 2 or 3 actually had higher complication rates as well as decreased complete resection rates. So this was one type of scoring system, and then this was specifically created for ESD, and it looked at, it came up with a novel clinical score model, again, that looks at tumor size, circumference of the lesion, anatomic location, and morphology, and looked at, it went through a very complex sort of system of being developed with a validation model, but overall this is what the score sheet looks like. You get points for lesions that are greater than 3 centimeters, for circumferentiality greater than 2 thirds, unfavorable locations like the cecum along a flexure or at the dentate line, and then morphology, specifically non-granular LSTs. And then the total points, we'll put it into a category of easy, intermediate, difficult, and very difficult. And through this study, you could see that the very difficult and very difficult had significantly higher times for resection. So here in the States, we don't really have a good system to develop, but something like this is something to consider, kind of assessing with your lesions that you're thinking about doing and putting it into one of these categories to either say, this is something I'll start with or this is something I'm going to not do right now, perhaps refer to someone I know who has a little bit more experience, and then come back to it once my learning curve has been, you know, I'm further along on my learning curve and I've done more cases. So this is what I would say in terms of thinking about should be in place before you tackle some of those cases which you now kind of assessed and thought about. The first is really, really, really know your knives. We all, we kind of sometimes learn on one or two knives depending on what we are allowed to buy from our hospital systems, but it's really important, and this is the incredible value of this course, is to understand the benefit that different knives provide you, whether it's the insulated tip or the jet knives or even scissor knives. Absolutely, the electrocautery setting talk that you just received is going to be one of your most valuable lessons because, you know, we, first of all, when we learned classic like ESD from years ago, we kind of sat on different like very set settings, but as you heard from Professor Yagi, even like closing the knife and using a certain setting versus opening the knife and using a low setting versus can replace like coag raspers. So understanding all of these subtleties of what you can do with different settings and different knives is really important to help you in those difficult situations that you're going to face. Traction techniques, we heard quite a bit about that, but practicing early on with easy lesions so you know exactly how to use the traction, the effect that the traction can create so when you get into the difficult situations, you can recognize that this would be a good time to use a certain type of traction. Positional changes, how does it, how does it affect if you put the patient on their back or on their side or move them throughout the procedure? It's important to become familiar with this as you're developing your practice early on. So again, you think about it more quickly when you're in a difficult case so that you don't end up spending two hours and then realizing, okay, I should change the position. Hemostasis techniques we've gone over quite a bit, but really again becoming proficient in those. And then most importantly is perforation management. I think that if you become proficient and confident in your perforation management, you actually can really tackle most situations because it takes away a certain degree of fear. Not all fear is always good, but it takes away a certain amount of fear that really lets you continue the objective of your procedure. So my tips are first in assessing the lesion beforehand. So the problem in the U.S. is that we don't have the ability to, in most cases, to bring patients, do an exam just to see what the lesion looks like. As Sergey said, they come from far away or, you know, they don't get paid for. So the notes that you get and the pictures are black and white because they get faxed to you. You have no sense really of like, you know, how hard it's going to be. So think about that a little. If you can manage to get that to help you decide, again, does it fit into any of those factors that make this a complex ESD, that can be really helpful. Think about changing position early on before you even start the resection just to see what the effect will be so that you can know, again, in which position to start and when you might consider changing your position. And even look in retroflexion. For example, in the colon, sometimes if the lesion is a little bit behind, it might really help you to start the procedure in retroflexion and get the oral side or similarly at the G-junction. And then consider your timing. So if you have one of those cases, you haven't really been able to assess the lesion beforehand, you get in there and you say, looking at this lesion, it's really going to take me four hours and I schedule an hour, delay or postpone that case. It's justified because it really is going to not only burden your team but yourself because you're going to be stressed during that procedure and it's going to affect how you are able to function. And also don't do these at the end of the day if things are getting delayed because if you need backup or you need to be able to take time, it's difficult. I definitely consider general anesthesia much more now for all upper procedures, but even colon ESD. I've moved towards intubating all right-sided lesions, all cases in which it's a right-sided lesion for multiple reasons. They tend to be longer. Those patients sometimes need to be moved. Our patients are obese, it can be very difficult to manage their airways. And also it does help with colon motility. It really does calm down the colon and it helps when you have to irrigate and stuff like that quite a bit. Consider your accessory devices like you just heard about. I think the Pathfinder is actually a game changer. I don't get support from that company so there's no disclosure there. But it has really converted procedures where it takes you even an hour just to get there and get in the right place to ones that you can actually do quickly and more efficiently in terms of the dissection techniques. And then really think about the technique are you going to use, whether it's pocket or tunneling or conventional based on the lesion. Give that thought beforehand so it, again, you can kind of use the easiest technique for that lesion. You heard it already. Use traction early. And since we don't have an ability like our colleagues do in Japan, which is to have hundreds and hundreds of cases and say, I'm only going to start with gastric and then I'm going to go to more complex, is think about using the traction techniques in those early lesions where they may not be as effective, but at least you're learning how to use it. And then it triggers you when you actually have those complex lesions. Control bleeding early so you don't run into situations of just not being able to see anything. Think about changing your knives. You don't have to be dedicated to one knife through the whole procedure. This is not about cost saving. And then always have your hotline available. So when you first start, when I first started, I always made sure my gastric surgeon was around in the hospital that day or my colon surgeon was around. I always, when I first started, I would call Norio and I said, I'm doing a case, case I need to FaceTime you, which I did. And I have fellows who do that with me now too. So, and industry as well, please take advantage of our industry partners who are here, who are experts in their own individual devices and can also see hundreds and hundreds of cases because they travel around the country and can give you really good advice about what to do in difficult situations. You've heard this already. These are the different traction methods. So I won't go into that more. It's just a quick video. So like this was a case where I, there's so much looping, it was a really obese patient. I just couldn't get the scope into a position where I could do this well. And so the first thing I did, I couldn't like see where the knife was. So I switched to a track, the insulated tip knife. And then I was finding that it was too floppy, so I needed to create traction in order to be able to more, you can see how far away, because any time I pushed in, I just got farther and farther. This was before we had Pathfinder. And so I created traction with that loop and click technique. And that allowed me to expose the fibers and to actually be able to use the insulated tip knife in the correct way. Which also helped with things like bleeding, because it exposed the tissue and then allowed me to sort of help control the bleeding a little bit more easily, because I could actually see the vessels and where I was coagulating. And then in this one, again, because of the patient's body habitus, I just couldn't get this into a position where I could get underneath it to start the initial incision. So I created a little bit of an incision and then applied traction. And what became sort of a lateral lesion, then very much to my advantage, just completely exposed the submucosal fibers, created a plane for me that I could nicely and efficiently go ahead and dissect. And Norio talked about like going over the fold. So there were like one or two folds in this situation, but you can clearly see by sort of the way the traction allows you to see where's muscle, where's submucosa, so you can actually follow that and avoid things like perforation. And again, it creates tension on the vessels, which allows you to even coagulate them as you're dissecting if they're small enough. And then lastly is, again, thinking about your traction techniques, the devices, and the physics of it. So this is not a true ASD, it's more of a third space procedure, but here we use this traction like a pulley method by really thinking about where we were applying the traction to help pull the tissue up, create the tension, create exposure of the fibers we needed that allowed us actually to do what I would call a subserosal dissection in this particular case. And when the clip didn't work, we switched to a more robust method with the suturing. Again, this is a very old video, so it was before some of the newer traction methods are available. This was a gist. So I actually have given a talk similar to this, just more based on like what you think about getting started. It's very rudimentary, but I really do think these things are important to think about in the beginning as you do get started, like what do you need. First and foremost is you need to have passion for what you're doing, getting into ESD. It shouldn't just be, and I don't think for any of you that's the case because you spent a lot of money, you invested, and you're here. But really understand the visualization, the classification systems to help you know when you should get started and when you shouldn't, or when you should do the procedure or not. Participate in a dedicated training program like this. Think about scope motion more than you may have before, as well as things like as the previous speakers have said, you know, moving your body and things like that. Definitely expect complications. Think therefore they're definitely going to happen, but just understand how you can manage them in ways that will allow you to complete the procedure. And then always be looking at the evolving techniques and innovations because they're going to help you learn more quickly. Absolutely have to build your team. Like during this time when you're training, before you've really started your clinical cases, this is what you should be doing, is making sure that your nurses and techs are also training on these devices. Some of them actually require their participation, like the Speedo. Talk to your surgical partners to make sure that you have those allies available when you start these cases that we talked about, the anesthesiologists as well, to help them understand any general for this colon procedure where they may be like, why are you, you know, why for a colonoscopy? And just really think about the teams of the people that are involved. And then talk to your marketing and development team because, again, most of our lesions are colon here. But I had the privilege of working with a Korean physician who saw a lot of patients that he did involved in a screening program for gastric cancer. And so my initial lesions were actually all gastric and really helped me build my learning curve a little bit more easily. But as you prepare and train, if you get involved in a, if you can get your marketing team to reach out and find those patients and develop that program, that's a way to help build those cases. And then definitely talk to your referring physicians about the need for their procedure. And talk to your surgeons as about the sort of back and forth exchange you can have between them with these patients. They send you patients, you'll end up sending them patients when they're not appropriate or when their ESD is diagnostic and suggests they need further surgery. And then absolutely must is have all of this equipment that you've heard about available. So and training is important. And I'm making these cases for a point that I hope to show you. So we learned from our Japanese colleagues, which is a very much an observational based program. They spend, they're all here probably wondering how it is that we're going to send you out in the world to do ESD so quickly. Because they spent years just watching one thing, watching gastric, watching colon, spending all that time doing it. Versus in the west, we're more based on self-study. We start with kind of learn EMR first and then go to ESD. And work on your own, work in labs, come to these training programs. Because we have to really find ways to bring those two training programs together given this difference in our situations with respect to our practices and the amount of time we have to spend in training. And this is a European guidelines. They are very similar. Start with EMR, learn the, you know, the basics about visualization, indications, work in an animal lab on X plants, then go to live cases, then antrum, rectum, work at, do a certain number of supervised cases, develop certain rates of on block resection, complication rates and that's how you progress. So I think also now we have a lot more in virtual training. There are many platforms that have hundreds of videos available. I would definitely advise that you take advantage of those. And hopefully, you know, our colleagues here can also share some of the time of those. FaceTime proctoring is really important. Again, with Norio, I would FaceTime him and say, should I cut there? And record and review your own procedures. So I would just say this is my journey really quickly. I was a fellow with Norio when he first started ESD in the U.S. at University of Colorado. I was an advanced fellow, so I was literally just standing there watching. But it absolutely made a difference for me in terms of my recognizing that I wanted to do this and follow more training. I started with ex vivo lesions and we had a supervised Japanese expert come in and teach us the ex vivo. We did about 40 lesions in two days, and then I went to live animals. I happened to have a lab at my hospital. I would bring industry in, we would start live cases, and then I actually got Norio privileges and put together three cases on the same day. And we did esophagus, he did esophagus, stomach, and rectum. And then after that, I FaceTimed him and that's how I developed my ESD learning curve as well as the poem I did in the same way. I then went to Japan. My observership was only two weeks, but for most people like Andy, I think, has spent a lot of time there. And others in the U.S. who started ESD early on had to spend a couple months or at least a couple weeks in Japan and certainly didn't have hands-on opportunities. But this was really meaningful to me, again, just to observe their methods and to get to see the units and the instruments and everything like that. So what I will tell you is that this course is my entire journey in just two days. So really just to show you the advantage and the privilege that you have that this course is providing you. Not only that, but I think that, like myself, I've been able to become faculty for this course many times thanks to Norio. I've directed other courses. I've participated in hands-on. I've now precept my fellows and I even perform, you know, ESD and stuff like that in live cases and have been able to gather experts and really put this knowledge out there. I think that comes from being a part of courses like this, learning from our experts, always continuing your relationships with them, and, you know, again, very accelerated for all of you. And this is just a future training opportunity if you want it in December. That's it.

endoscopic submucosal dissection

difficult ESD

scoring systems

knives

traction techniques

perforation management